"American Society of Hematology. Before the specimen is transferred to a container with anticoagulant, some of the already clotted specimen may be submitted for permanent histology in formalin. A moderately or markedly cellular sample is composed of a virtually exclusive population of Hrthle cells, yet the clinical setting suggests a benign Hrthle cell nodule, eg. 8600 Rockville Pike Effect of the Bethesda system for reporting thyroid cytopathology on thyroidectomy rates and malignancy risk in cytologically indeterminate lesions. The rate of malignancy in FNA-BRAF positive nodules has been shown to be 99.8%[55]. The nuclei are hyperchromatic, uniform in size and shape, and with indinstinct nucleoli. Ghossein Pan-keratin is the most reliable positive immunostain in UTCs, acquiring an expression ranging from 50% to 100%. et al. Anaplastic carcinoma of the thyroid: a review of 84 cases of spindle and giant cell carcinoma of the thyroid. BRAF is not usually found in the follicular variant of papillary thyroid carcinoma, but is increasingly detectable in each step of dedifferentiation, including tall cell tumors and anaplastic cancer. Picture of four bone marrow specimens in a slide tray. Intranuclear inclusions and multinucleated cells have been reported. Most primary thyroid malignancies with the exception of follicular and Hurthle cell carcinomas have unique cytological features which can differentiate primary malignancies from other thyroid lesions. Gharib The morphologic findings are very similar to that of the aspirate smear, with the caveat that it only represents the cells that slough off. A benign result is obtained in 60% to 70% of thyroid FNAs. Wu HH, Rose C, Elsheikh TM. "Demystifying the Bone Marrow Biopsy: A Hematopathology Primer, 01 May. Frontiers | A Whole-Brain Cell-Type-Specific Sparse Neuron Labeling Maybe a routine peripheral smear caught some circulating blasts. The most common scenarios can be described as follows: There is a prominent population of microfollicles in an aspirate that does not otherwise fulfill the criteria for follicular neoplasm/suspicious for follicular neoplasm. This situation may arise when a predominance of microfollicles is seen in a sparsely cellular aspirate with scant colloid. KH The Paris System for Reporting Urinary Cytology tried lately to address adequacy. A significant proportion of these cases (16%25%) prove not to be neoplasms but rather hyperplastic proliferations of Hrthle cells in nodular goiter or lymphocytic thyroiditis.26,27 About 15% to 45% of nodules are malignant, and the remainder of the neoplasms prove to be Hrthle cell adenomas.22,26,27, Many thyroid cancers, most especially papillary thyroid carcinoma (PTC), can be diagnosed with certainty by FNA. G RA The cells have abundant pink cytoplasm, basally located nuclei and nuclear features of conventional PTC. The nuclei are enlarged, with usually an oval or irregular shape, and include intense nuclear grooves and inclusions. Layfield Approximately 3% to 7% of thyroid FNAs have conclusive features of malignancy, and most are papillary carcinomas.1013 Malignant nodules are usually removed by thyroidectomy, with some exceptions (eg, metastatic tumors, non-Hodgkin lymphomas, and undifferentiated carcinomas). Clinical outcome for atypia of undetermined significance in thyroid fine-needle aspirations: should repeated fna be the preferred initial approach? Fine-needle aspiration (FNA) has an essential role in the evaluation of euthyroid patients with a thyroid nodule. Of those that prove to be malignant, many are FCs, but a significant proportion are follicular variants of papillary carcinoma.2,8,11,19. This resulted in diagnostic inconsistencies among different laboratories and difficulty in communicating the implications of thyroid fine-needle aspiration (FNA) results both to clinicians (endocrinologists and endocrine surgeons) and laboratory doctors (pathologists and radiologists)[6]. LiVolsi Layfield LJ, Cibas ES, Gharib H, Mandel SJ. Moreover, large, atypical, histiocytoid cells with enlarged nuclei and abundant vacuolated cytoplasm usually coexist. Since the marrow is abundantly deep red and more viscous than blood, the red cell and platelet components will eventually form clots if no anticoagulant is present. (10%) PTC most commonly metastasizes via lymphatics. There are three main methods of sample preparation; smears, liquid-based preparations, and cell block--these preparation methods may be used singly or in . Lymphadenopathy is also present in one quarter to half of patients, whereas the lungs is the most common site of metastases[49,50]. Q: Can your pathologist give you a preliminary assessment of the aspirate smear or flow cytometry analysis on the same day as a procedure if it was performed early in the morning? Note: Please review ASHs disclaimerregarding the use of the information contained in these articles. This variant of PTC is not common, but it is important to be recognized as it may be confused with a Hurthle cell neoplasm[44]. The second subcategory includes cases with nuclear atypia, such as the presence of occasional nuclear grooves, nuclear crowding, and abnormal chromatin pattern, which are characteristics of papillary carcinoma (PTC). 119 0 obj <>/Filter/FlateDecode/ID[<80B644DBD03A284F83277CD8A09960C6><94D1BF37A2B04B428378CFB47946E293>]/Index[92 53]/Info 91 0 R/Length 121/Prev 842357/Root 93 0 R/Size 145/Type/XRef/W[1 2 1]>>stream Vimentin immunoexpression is also a common finding[52]. Verizon (United States of America)Cell Tower Map - CellMapper et al. JA Every thyroid FNA must be evaluated for adequacy. Benign cyst-lining cells are typically polygonal or fusiform with abundant cytoplasm, well-defined cellular borders, sometimes enlarged, grooved nuclei, and small distinct nucleoli. Sparsely cellular specimen means exact what it says - cells are sparse. There are also sheets of follicular cells with large pale nuclei and some with nuclear grooves, but without intranuclear inclusions. The heterogeneity of this category precludes outlining all scenarios for which an AUS interpretation is appropriate. For that reason the aspirate is then classified as AUS/FLUS to indicate the uncertainty of the findings. et al. Human immunodeficiency virus (HIV)-associated cystic lymphoepithelial lesions. et al. Chronic sialadenitis: sparsely cellular specimen with fewer lymphocytes and germinal center fragments; no characteristic lymphoepithelial islands. These can be highly useful when a core biopsy is suboptimal, demonstrates marked myelofibrosis, is a dry tap, or otherwise fails to provide adequate visual data for morphology, architecture, cellularity, and hematopoietic lineage assessments. Such cases represent a minority of thyroid FNAs and in the Bethesda System are reported as atypia of undetermined significance (AUS) or follicular lesion of undetermined significance. The necessity for this category was debated at the NCI conference, after which a vote (limited to the clinicians in attendance) was taken, and the majority voted in favor of this category. et al. . Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. The National Cancer Institute Thyroid fine needle aspiration state of the science conference: a summation. . VanderLaan PA, Marqusee E, Krane JF. Jo VY, Stelow EB, Dustin SM, Hanley KZ. Preparation Methods Research is directed to the identification of molecular markers that, in conjunction with FNA, can identify patients with a malignant nodule. Cystic degeneration also is often found. Proposal of the SIAPEC-IAP Italian Consensus Working Group. Such cases occur with some regularity, and they are best classified as suspicious for malignancy, qualified as suspicious for papillary carcinoma. Nodules called suspicious for papillary carcinoma are resected by lobectomy or thyroidectomy. Ohori NP, Singhal R, Nikiforova MN, Yip L, Schoedel KE, Coyne C, McCoy KL, LeBeau SO, Hodak SP, Carty SE, et al. CB Renshaw AA. As a medical procedure, bone marrow collection may sometimes have limitations in obtaining adequate specimens. There was also a great difference regarding the percentage of the cases classified into the TIR 2/ DC II (benign) category (83.9%) compared with approximately half (55.4%) of the cases in the 6-tiered system. This is the most common variant of PTC and is characterized by a predominantly follicular architecture. The double needle from the same aspirate procedure is used to cut a core biopsy of optimal length (longer is better; i.e., more data). Characteristically, distinct granules (calcitonin granules) are spotted in the cytoplasm of the cancer cells, as well as eccentric nuclei, indicating a plasmacytoid appearance to the tumor cells. MS Loose cellular material can be held together to make into a cell block in all of the following EXCEPT a. agar b. albumin c. blood clot d. resin resin A slide of breast fluid has the cells washing off during staining. Unlike the core biopsy, decalcification is not required for the clot section. Benign follicular nodules often have a small population of microfollicles and crowded groups. Figure 2. The specimen is usually cellular with polygonal cells in loose papillary clusters with abundant eosinophilic cytoplasm. The atypia of undetermined significance/follicular lesion of undetermined significance: malignant ratio: a proposed performance measure for reporting in The Bethesda System for thyroid cytopathology. Cantara S, Capezzone M, Marchisotta S, Capuano S, Busonero G, Toti P, Di Santo A, Caruso G, Carli AF, Brilli L, et al. Salivary Glands and Other Head and Neck Structures of value in acquiring a cellular sample, possibly due to increasing hemodilution. The cellular sample is typically monomorphic, although some specimens may appear pleomorphic; the cells are usually small or medium-sized, noncohesive, and contain an eccentrically located nuclei[35]. Without the bone marrow matrix, these slides contain only cells directly from the marrow and can be stained and assessed both for lineage and cytologic morphology, with high correlations to what may be seen on aspirate and biopsy. As such, if a dry tap is encountered during a bone marrow procedure, it may be beneficial to obtain two bone core biopsies to send to the laboratory. ES The recommended management is clinical correlation and a repeated FNA at an appropriate interval.2,15 In most cases, a repeated FNA results in a more definitive interpretation; only about 20% of nodules are repeatedly AUS.2 In some cases, however, the physician may choose not to repeat the FNA but observe the nodule clinically or, alternatively, to refer the patient for surgery because of concerning clinical and/or sonographic features. The individual tumor cells are enlarged, oval in shape with eosinophilic cytoplasm; the nuclei show elongation, oval shape, membrane thickening, chromatin clearing, grooves, and inclusions. Management of a solitary thyroid nodule. Agrawal S, Rao RS, Parikh DM, Parikh HK, Borges AM, Sampat MB. D If these constitute the minority of the follicular cells, they have little significance and the FNA can be interpreted as benign. This document summarizes several years of work, begun as a Web-based discussion, followed by a live conference, and culminating in the production of a print and online atlas. Gross specimen was measuring about 2x2x1.5 cm in size, soft in consistency, brownish black in color and roughly oval in shape [Table/Fig-4]. Hematopathologists can assess morphology, histologic architecture, and immunologic and phenotype profiles (Figure 2) across all four components to create a comprehensive report for your patient. PDF The Bethesda System for Reporting Thyroid Cytopathology sharing sensitive information, make sure youre on a federal V Moses et al[60] also examined the clinical utility of the above panel in thyroid FNA biopsies. Enter your ZIP Code, or City and State below to find the stores nearest you and a listing of the device models available within each. Search for other works by this author on: Fine-needle aspiration biopsy of thyroid nodules: impact on thyroid practice and cost of care, Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation, The Bethesda System for Reporting Thyroid Cytopathology, Diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference, The: National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference: a summation, Fine-needle aspiration cytology of the thyroid, 1980 to 1986, Long-term follow-up of patients with benign thyroid fine-needle aspiration cytologic diagnoses, Usefulness of fine-needle aspiration in the diagnosis of thyroid carcinoma: a retrospective study in 37,895 patients, Accuracy of thyroid fine-needle aspiration using receiver operator characteristic curves, Fine-needle aspiration of thyroid nodules: a study of 4703 patients with histologic and clinical correlations, Accuracy of fine-needle aspiration of thyroid: a review of 6226 cases and correlation with surgical or clinical outcome, Fine-needle aspiration cytology of the thyroid: a 12-year experience with 11,000 biopsies, Non-diagnostic fine-needle aspiration biopsy: a dilemma in management of nodular thyroid disease, Value of repeat fine needle aspiration (FNA) of the thyroid [abstract], Post thyroid FNA testing and treatment options: a synopsis of the National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference, Atypical cells in fine-needle aspiration biopsy specimens of benign thyroid cysts, NCCN thyroid carcinoma practice guidelines, Fine-needle aspiration of follicular lesions of the thyroid: diagnosis and follow-up, Diagnosis of follicular neoplasm: a gray zone in thyroid fine-needle aspiration cytology, Factors that predict malignant thyroid lesions when fine-needle aspiration is suspicious for follicular neoplasm., Thyroid cytology and the risk of malignancy in thyroid nodules: importance of nuclear atypia in indeterminate specimens, Fine-needle aspiration biopsy of the thyroid: an appraisal. Extra smeared slides are kept unstained for possible subsequent ancillary staining (e.g., MPO, PAS, esterases). The 6 general diagnostic categories are shown in bold type in Table 1. The site is secure. The accuracy of fine-needle aspiration biopsy and frozen section in patients with thyroid cancer. Ramzy Almost simultaneously, in Europe, the British Thyroid Association-Royal College of Physicians and the Italian Society for Anatomic Pathology and Cytopathology-International Academy of Pathology (SIAPEC-IAP) thyroid reporting systems, each comprised of 5 diagnostic classes, have been introduced[10,11]. However, in almost 25%-30% of cases, MTC is inherited, and is associated with one of three familial syndromes: Multiple endocrine neoplasia (MEN) syndrome type 2A (Sipples syndrome), MEN type 2B (mucosa neuroma syndrome or Gorlins syndrome), and familial MTC[35]. . Thyroid nodules is a very usual clinical problem, as it is diagnosed in approximately 60% of the general population in Western countries[1]. Many laboratories have traditionally considered a macrophages-only sample unsatisfactory and included them in the ND/UNS category, with the understanding that, because the parenchyma of the nodule has not been sampled, one cannot exclude a cystic papillary carcinoma. "Agar Cell-Suspension": A Novel Technique for Processing Clear Specimens. Goellner However, we cannot answer medical or research questions or give advice. Any specimen that contains abundant colloid is adequate (and benign), even if six groups of follicular cells are not identified: a sparsely cellular specimen with abundant colloid is, by implication, a predominantly macrofollicular nodule and therefore almost certainly benign. Figure 1. et al. Baloch hb```f``jg`e`bf@ a=TbO>9\!@)s\2q F)}w38|)0KQD[Vi>Rc@8[@5ii` .Q@q!d - `' }i@&QAz@%,700g& pL`r, l|Bj2"BTg]((@G@{2L2xVWA0Kk3\2 Ii Since the PTC-FV variant represents one of the most common causes of a false negative diagnosis of PTC, it is important to distinguish this PTC variant from other benign conditions, such as a follicular neoplasm or adenomatous nodule. These indeterminate results imply surgeons to consider alternative therapies (e.g., thyroid lobectomy with intraoperative frozen section). EK Such atypia may result from a variety of benign cellular changes, but in some cases may reflect an underline malignancy which has been suboptimally sampled or has intermediate diagnostic features[20-22]. An AUS result is obtained in 3% to 6% of thyroid FNAs.2,10 Higher rates likely represent overuse of this category when other interpretations are more appropriate. They are then stained and processed much like the original core biopsy. Another diagnostic option for patients with repeat ultrasonography-guided FNA of thyroid nodule with non-diagnostic cytology results, would be the utilization of ultrasonography-guided core needle biopsy[39]. One subcategory includes cases with a microfollicular pattern and minimal colloid, that is, follicular lesion of undetermined significance (FLUS). Another pitfall encountered with cystic thyroid nodules are the atypical cyst-lining cells[24]. Herein lies everything you were afraid to ask. Rossi Papillary structures are not as common as it was believed, because intact papillae are often too large to enter the fine needle or are disrupted during the preparation of the smears. Bongiovanni M, Krane JF, Cibas ES, Faquin WC. After patient preparation, sedation, and the procedure itself, a bone marrow investigation provides four specimen types for pathologist review (Figure 1): the bone marrow core biopsy, the bone marrow touch imprint, the bone marrow aspirate smear, and the bone marrow clot particle. If no aspirate is collected, then an extra core biopsy specimen can be agitated to release cells for flow cytometry; however, this is not ideal. the contents by NLM or the National Institutes of Health. Auger M, Stelow EB, Yang GCH. Taken together, the study results confirmed several tenets of TBSRTC approach to adequacy: 1) A sample should be considered ND/UNS if it is sparsely cellular, even if there are a few groups of. ES The high sensitivity rate, as well as the high negative prognostic value of BRAF testing in AUS/FLUS and SFN/SFN categories have been also demonstrated by Alexander et al[57]. Schlinkert The diagnosis of MTC can be confirmed by simply measuring serum calcitonin levels, which are markedly elevated in the majority of cases (> 10 pg/mL)[48]. RT The Bethesda System For Reporting Thyroid Cytopathology. H Among thyroid malignancies, PTC has the highest propensity to appear cystic, as 10% of the PTC specimens are entirely cystic. Oral Cysticercosis- A Diagnostic Dilemma - PMC - National Center for Giorgadze One nucleus has an apparent intranuclear pseudoinclusion (arrow). FOIA 2. Dr Love Will you tell me what sparsely cellular specimen And DeLellis M The cytotechnologist is specially trained and certified to examine cellular samples under a microscope, evaluating the slides for specific abnormalities in the cell's shape, color, or size which could signal a cancerous process or other disease. JR et al. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM. Crowded macrofollicles with mild irregularities in nuclear membrane and prominent nucleoli in a specimen with scant colloid ( 40 pap stain on ThinPrep slide) (diagnostic categories III). Chung These include hypocellular smears with extensive cystic degeneration with rare follicular cells with nuclear atypia indicative of PTC. Gharib The disc is then wrapped in tissue paper and paraffin processed as for a biopsy specimen. You order a bone marrow analysis for your patient. A malignant thyroid FNA diagnosis accounts for 4%-8% of all thyroid FNAs, the majority of which are PTCs, and these patients will require thyroidectomy[53]. Cytopreparatory Techniques | SpringerLink These changes are not pathognomonic, as they are frequently detected in some PTCs, especially in the follicular variant, and in benign lesions as well, such as follicular adenomas. The 2017 Bethesda System for Reporting Thyroid Cytopathology This category refers to cellular specimens with abundant follicular cells arranged in a microfollicular pattern with minimal colloid. Faquin IR The Bethesda System for Reporting Thyroid Cytopathology is the most preferred system for the diagnosis of FNA specimens, which also contains guidelines for the diagnosis and treatment of indeterminate cases. et al. Enlarged follicular cells arranged in monolayer sheets and follicular groups with nuclear elongation and chromatin clearing in a follicular variant of PTC case ( 40 pap stain on ThinPrep slide) (diagnostic categories VI). . Royal College of Physicians. hWkO+t{9! x,{d^O*D Quick tip: Flow cytometry cannot be performed on the clot section after the clot has set and after fixation in formalin. Role of repeat fine-needle aspiration biopsy (FNAB) in the management of thyroid nodules. Prognosis is dismal with a mean survival of 2.5 to 6 mo and an overall 5-year survival of 0% to 14%. Like the marrow aspirate smear, touch imprint preparations provide a quick turnaround time (i.e., do not need decalcification) and great morphologic detail (if the aspirate smears are paucispicular or hemodiluted). The risk of malignancy for an AUS nodule is difficult to ascertain because only a minority of cases in this category have surgical follow-up. AA Malignancy risk for fine-needle aspiration of thyroid lesions according to the Bethesda System for Reporting Thyroid Cytopathology. We reviewed the English literature regarding Thyroid Cytopathology systems in order to identify the most suitable methodology, taking into account our prospective as well. Pathology Outlines - Suspicious for malignancy et al. In such laboratories, macrophages only often constituted the great majority of ND/UNS cases, with rates that ranged from 15% to 30%.2,9,11,12 Other laboratories considered the risk of a false-negative result negligible and reported macrophages only as benign.10,11 At the 2007 NCI Conference, it was decided that cyst-fluid-only (CFO) cases should be considered a clearly identified subset of ND/UNS. This category also includes cases with a predominant population of Hurthle cells; these cases are labelled Hurthle cell neoplasm (Figure (Figure3).3). The first draft of the committees summary documents was posted on the Web site and open for online discussion from May 1 to June 30, 2007. Pathology and Genetics of Tumours of Endocrine Organs, Genetic and biological subgroups of low-stage follicular thyroid cancer. The prepared core biopsy slides can be used for immunohistochemical (IHC) investigations (phenotyping the cells using IHC stains), and an initial standard hematoxylin and eosin stain is done to assess baseline histology. Renshaw noted that a Hurthle cell neoplasm demonstrating one of the following features: Small cell dysplasia, large cell dysplasia, severe nuclear crowding, and dishesive cellular pattern is usually associated with a high risk of malignancy[33]. and transmitted securely. Immediately after the core biopsy is obtained, the procured tissue is "touched" several times onto glass slides. Papillary thyroid carcinoma and variants. Map ; Apps; Tools . Seventeen . View an interactive bone marrow clot specimen online. However, the percentage of the cases classified into the TIR 3/DC IV (follicular proliferation/neoplasm) category was substantially smaller (4.6%) in the 5-tiered system compared with the 6-tiered system (23.8%). Inclusion in an NLM database does not imply endorsement of, or agreement with, Note granulocytic precursors (arrows) and erythroid cells (arrow heads). These features could be intranuclear inclusions, nuclear grooves, or psammoma calcifications; (6) DC VI Malignant (Figures (Figures55--7).7). The positive predictive value of a malignant FNA interpretation is 97% to 99%. The tall cell variant of PTC is an important subtype with a potentially aggressive clinical course. Two-dimensional fixed tissue specimens from the biopsy and clot are easily stained with immunohistochemical methods while three-dimensional, liquid cellular content can be assessed with flow cytometry. Neither of these patterns fits comfortably into the benign category, but the changes are insufficient for any of the more . However cases with indeterminate cytological findings still remain a matter of debate. Although these cytomorphologic features do not permit distinction from a follicular adenoma (FA), they are reportable as follicular neoplasm (FN) or suspicious for a follicular neoplasm (SFN), leading to a definitive diagnostic procedure, usually lobectomy.12,15,17 The term suspicious for a follicular neoplasm is preferred by some laboratories over follicular neoplasm for this category because a significant proportion of cases (up to 35%) prove not to be neoplasms but rather hyperplastic proliferations of follicular cells, most commonly those of multinodular goiter.10,1821 About 15% to 30% of cases called FN/SFN prove to be malignant.2,10,19,22 The majority of FN/SFN cases turn out to be FAs or adenomatoid nodules of multinodular goiter, both of which are more common than FC.
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